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About
Testimonials
Faqs
Services
Cash Back Program
Not Your Fault Claim
Ride-Share Vehicle Claims
Loss Of Income Claims
Fleet Services
Claim Form
Contact Us
Insurance Claims VLog
Motor Claim Form V2
No Stress Accident Management
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OUR CLIENT DETAILS
Vehicle Owner Surname
Vehicle Owner First Name:
Driver Surname
Driver First Name
Address
Phone
Email
License number
VEHICLE DETAILS
Make
Model
Year
Registration
Registered for GST? (please tick one)
Yes
No
AT FAULT PARTY DETAILS (NEGLIGENT PARTY)
Surname
First Name
Address
Phone
Email
License Number
VEHICLE DETAILS
Make
Model
Year
Registration
INSURANCE DETAILS
Insurer
Claim Number
ACCIDENT DETAILS
Date of Loss and Time of Incident
*
Date
Time
Accident Location and/or Suburb
*
VERSION OF EVENTS AND DIAGRAM/SKETCH
Please Provide a Brief Description
*
Damage to My Car (Select all that apply)
*
Front of Car
Back of Car
Driver Side
Passenger Side
Top of Car
Damage to Other Car (Select all that apply)
Front of Car
Back of Car
Driver Side
Passenger Side
Top of Car
Please Provide Image of Damaged Areas
Click or drag files to this area to upload.
You can upload up to 10 files.
INDEPENDENT WITNESS DETAILS AND/OR EMERGENCY SERVICES E.G. Victoria Police Members
Full Name
Email Address
Contact number and/or Address
AUTHORITY TO ACT | MOTOR ACCIDENT CLAIM/PROPERTY DAMAGE CLAIM
Full Name
*
(If claim is for a company vehicle, director full name and signing of this document is required)
Mailing Address
*
Contact Phone Number
*
Email Address
*
Signed
*
Clear Signature
Dated
*
Checkboxes
I/We the undersigned, hereby authorise My Motor Claim to act on my/our behalf in all matters relating to my/our motor vehicle accident claim including discussing, obtaining and signing of all documents relating to this matter. I/We further and explicitly express in writing herein that all communications pertaining to this matter are to be directed to My Motor Claim.
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